Medical physics aspects of cancer care in the Asia Pacific region: 2011 survey results

Background: Medical physicists are essential members of the radiation oncology team. Given the increasing complexity of radiotherapy delivery, it is important to ensure adequate training and staffing. The aim of the present study was to update a similar survey from 2008 and assess the situation of medical physicists in the large and diverse Asia Pacific region. Methods: Between March and July 2011, a survey on profession and practice of radiation oncology medical physicists (ROMPs) in the Asia Pacific region was performed. The survey was sent to senior physicists in 22 countries. Replies were received from countries that collectively represent more than half of the world’s population. The survey questions explored five areas: education, staffing, work patterns including research and teaching, resources available, and job satisfaction. Results and discussion: Compared to a data from a similar survey conducted three years ago, the number of medical physicists in participating countries increased by 29% on average. This increase is similar to the increase in the number of linear accelerators, showing that previously identified staff shortages have yet to be substantially addressed. This is also highlighted by the fact that most ROMPs are expected to work overtime often and without adequate compensation. While job satisfaction has stayed similar compared to the previous survey, expectations for education and training have increased somewhat. This is in line with a trend towards certification of ROMPs. Conclusion: As organisations such as the International Labour Organization (ILO) start to recognise medical physics as a profession, it is evident that despite some encouraging signs there is still a lot of work required towards establishing an adequately trained and resourced medical physics workforce in the Asia Pacific region.


INTRODUCTION
The International Labour Organization (ILO) has recently classified 'medical physicist' as an occupation in the International Standard Classification of Occupations-08 (ICSO-08) under physicists and astronomers [1]. This is indicative of the increasing awareness of medical physics as a profession in its own right. While the actual number of medical physicists is relatively small compared to other professional groups in medicine, they perform a vast variety of different tasks. This applies also to its subspecialty of radiation oncology medical physics, in which the majority of medical physicists work.
In 2008, a survey was conducted to determine the characteristics of the medical physics workforce in countries within the region of the Asia-Oceania Federation of Organizations for Medical Physics (AFOMP) [2]. It probed workforce numbers and typical workloads, training and education, and job satisfaction among medical physicists working in radiation oncology in 16 countries in the Asia Pacific region. The aim of the present study was to update this information three years after the initial survey. In addition to this, questions on certification and research opportunities were added to enrich the data and reflect on recent trends in health professions.
As in 2008, the definition of the clinical medical physicist used was that of the AFOMP [3]. It is worth repeating here: "A qualified Clinical Medical Physicist is a person who is qualified with a master university degree or equivalent in physical science or engineering science and working in alliance with medical staff in hospitals, universities or research institutes. In addition to his/her university degree or equivalent, a Clinical Medical Physicist shall have specialist training in the concepts and techniques of applying physics in medicine including training in the medical application of both ionizing and non-ionizing radiation. This person must have a thorough knowledge in one or more sub-fields of medical physics, including radiotherapy physics, imaging physics, nuclear medicine physics and radiation protection." A key point in this definition is that a medical physicist has both a sound theoretical understanding of the science as well as clinical training in its application. As technology advances rapidly, an additional requirement is commonly the participation in Continued Professional Development (CPD) [4,5]. This requires significant resources that may not be available everywhere. There is therefore an important role for professional organisations such as the AFOMP, which has the mission to advance and standardise medical physics practice in the region. In this context, AFOMP has initiated a periodic survey of medical physics practice in the region, the first of which was conducted in 2008. The present report summarises the outcomes of the second survey in 2011.
Specifically, it is the aim of the present article to: • Document differences and commonalities in education and clinical experience required for radiation oncology medical physicists (ROMPs) in the Asia Pacific region, • Update general information on the number of physicists and their relation to equipment and other professions, • Document the tasks undertaken by physicists in radiation oncology, including research and teaching, and • Explore resources, status and job satisfaction available to and among medical physicists. Where possible, comparisons with the 2008 survey have been included to highlight any changes over the three-year period.

METHODS
Based on the 2008 survey [2], a questionnaire was designed to explore medical physics practice in radiation oncology. The 2008 survey relied on an ad-hoc group of medical physicists in 16 countries to provide information on the situation in these countries. As this approach was successful, a similar approach was used in 2011. The questionnaire was sent to 20 senior physicists in the region who have been active in the field for several years. Many of them have represented their medical physics organisations at AFOMP, the International Organization of Medical Physics (IOMP), and the International Atomic Energy Agency (IAEA) and were, as such, considered to be familiar with the state of medical physics in their respective countries. Including the initiators of the survey, the questionnaires reached 22 countries and territories in the Asia Pacific region.
The questionnaire was distributed in English and covered seven main areas in five themes with all * IMRT = Intensity Modulated Radiation Therapy, IGRT = Image Guided Radiation Therapy, HT = Helical Tomotherapy, CK = Cyberknife, GK = Gammaknife, PT = proton and particle therapy, MT = microtron based radiotherapy, SRS = stereotactic radiosurgery questions asked in 2008 included (some with minor clarifications). Some additional questions were included to probe important areas further.

Education, training and professional certification
In addition to questions on expected training, education and CPD, the questionnaire probed the availability of a certification scheme.

Staffing numbers and treatment equipment
This section also included an assessment of the ratio of ROMPs to other professions and the overall population in participating countries. Most updated information on population numbers was taken from Wikipedia (en.wikipedia.org). It reflects data from 2010 or 2011 in all cases. Information on equipment provided in the questionnaires was supplemented with data from the Directory of Radiotherapy Centres (DIRAC) database maintained by the International Atomic Energy Agency (IAEA) (http://nucleus.iaea.org/HHW/DBStatistics/DIRAC/inde x.html).
3. Workload This part of the questionnaire was enlarged compared to 2008 to provide more details on the typical activities of ROMPs in the region. For example, information technology (IT) was explicitly included and This page number is not for citation purposes we also inquired about the requirement for ROMPs to work overtime. 4. Professional organisations 5. Resources available 6. Research and teaching 7. Job satisfaction in the areas of professional recognition, remuneration, and workload.
In addition to this questionnaire, participants were invited to provide as many free form comments as necessary. The questionnaire was sent out by email in March 2011 and the original time frame for answering the questions was four weeks; however, answers were accepted beyond the four-week period. They reflect the status of March to August 2011. On some occasions, additional details were elicited and provided in communication with participants.

Answers
were received from all 22 countries/territories, representing more than 3500 medical physicists. This constitutes a response rate of 100% compared to 80% in 2008 [2]. Tables 1 to 5 show the results. The numbering and structure of the tables is identical to that used in the original publication [2] to facilitate easy comparisons. Two tables (2 'staff numbers and equipment' and 3 'workload') were split into two tables each to make access to the data easier. Table 2 also contains a direct contrasting of figures from 2008 and 2011.
As in 2008, about half of the respondents provided additional information in free form. This information was included in the tables wherever possible and additional comments shown are in table 5.

DISCUSSION
As the profession of medical physicists is maturing and international organisations such as the IAEA and the IOMP are aiming to standardise education and practice, it is of interest to explore how medical physicists fare in the Asia Pacific region. The fast and comprehensive reply of respondents in all countries/territories approached illustrates that this interest is shared by ROMPs. The higher response rate (100% in 2011 compared with 80% in 2008) may reflect increasing professional awareness but could also be a result of allowing more time for completion of the questionnaires. This page number is not for citation purposes

Education, training and professional certification
As in 2008, all respondents agreed on the need for a combination of academic education and clinical training. This is in line with developments all over the world. In most countries, the need for postgraduate education specialising in medical physics was also acknowledged. It will be a challenge to ensure that access to these courses is available everywhere. The internet provides a unique opportunity here and web-based resources can at least provide some of the required content [6]. While the need for a PhD [7] is not apparent in the answers, Table 1 shows that several countries give candidates with a PhD advanced standing and reduce requirements for other training. This practice needs to be considered case by case as academic education cannot necessarily replace clinical experience.
There is no doubt that medical physicists working in radiation oncology require a high level of training and specialisation. Taking into account a higher degree and clinical training that typically takes at least two years, entry into the profession typically requires at least seven years of specialist education after high school completion. As such, ROMPs are amongst the most highly trained professionals without a medical degree in hospitals.
It is therefore not surprising to find a trend towards a requirement for professional certification of medical physicists [8,9]. Patients and other medical professionals find it difficult to judge the competence of ROMPs. As such, they need to rely on peer review and assessment to ensure that skills and experience of medical physicists are appropriate for the complexity of the tasks to be undertaken. This is particularly important as ROMPs are often engaged in work with significant safety implications for patients, staff, and the public. Radiation protection is one of these areas and ROMPs in all surveyed countries spend at least one hour per week on average on this activity, as can be seen in Table 3a. This page number is not for citation purposes While the survey did not probe if certification was actually required in a country to practice medical physics, it can be assumed that this is likely to become the norm in the future.
In the context of certification and credentialing, professional organisations play an essential role. As such it is good to see in Table 4 that most countries/territories have a professional association that represents medical physicists and, at least in principle, could oversee a certification scheme. International organisations such as IOMP and AFOMP can facilitate communication between these organisations, possibly help with mutual recognition, and further assist in defining standards to assess medical physics practice.
Finally, it is important to note that CPD is an integral part of most certification procedures [9,10]. In a fast-changing technological environment such as radiation oncology medical physics, this is particularly essential. As such, education of ROMPs does not end with graduation and there could be opportunities for This page number is not for citation purposes * Categories: excellent: e, good: g, acceptable: a, not adequate: n using educational materials both during the training of students as well as for CPD of experienced ROMPs. This could overcome some of the problems associated with economies of scale in developing educational materials for a small but highly specialised profession.

Resources and staffing
As can be seen in Table 2a, the number of medical physicists in the region has increased by 29% since 2008. This increase applies to virtually all countries with a notable exception of a few smaller workforces. However, the number of megavoltage treatment units in the region has also increased significantly since 2008 and therefore the ratio of machines per ROMP has only decreased slightly as can be seen in Table 2b. In 2009, AFOMP published its recommendations for staffing levels for medical physicists [11]. Given the variation in practice, it is difficult to apply these figures rigorously; however, given the complexity of work, it appears that the present number of ROMPs is still on the low side of these recommendations. This page number is not for citation purposes  Table 2 also shows that many countries have implemented intensity modulated radiation therapy (IMRT) [12,13] and image guided radiation therapy (IGRT) [14,15]. As a matter of fact, these technologies have become so widely used that some respondents did not even mention them in the survey. The availability of complex treatment units such as Cyberknife surgery and helical tomotherapy has also increased substantially from 2008 to 2011. While the availability of equipment does not necessarily indicate its extensive use, the commissioning of equipment -which is independent of workload -is one of the core activities of medical This page number is not for citation purposes physicists in radiation oncology [16]. Additional tasks such as planning and individual patient quality assurance (QA) will increase with clinical utilisation, increasing the workload as the added complexity presents additional risks and thus requirements for QA [17,18]. Table 4 shows that access to the Internet is now available virtually everywhere. This provides significant opportunities for the future as the Internet has become an essential tool for information exchange and access to resources for medical physicists. On the other hand, the availability of specialised dosimetric equipment has not improved dramatically since 2008. Given the increasing complexity of the equipment in most countries, this is of considerable concern.
Typical tasks and workloads for ROMPs As can be seen in Table 3a, most of the workload for ROMPs is clinical with treatment planning being the predominant role in most countries. As such, it is fair to say that ROMPs are members of the clinical team directly involved in patient care (albeit not always with patient contact). However, the survey shows that ROMPs also spent a significant amount of time on a large variety of duties including provision of information technology services and radiation protection. The results of this part of the survey illustrate a shortcoming of the simple questionnaire as the large variety of work practices had to be compressed into few categories. This will result in some variation in the interpretation of the answers.
However, there is no doubt that there is significant breadth in the work of medical physicists. This is also illustrated in their involvement in research and teaching, as shown in Table 3b. As can be seen, many physicists are involved in education of other professionals in the hospital environment. This confirms the importance of medical physics concepts but also exposes a shortcoming as most medical physics training does not include teaching and communication skills. Similarly, future training requirements would also need to consider research and professional ethics [19]. Table 3b also summarises the results of the questions regarding overtime. Given the nature of medical physics work, it is common that out-of-hours work is required. This is often in the form of overtime that extends work hours beyond normal working hours. As Table 3b shows, ROMPs in most countries are required to perform overtime work. It is concerning that this is expected but often not adequately compensated. The routine requirement for overtime work also confirms the fact that staffing levels are typically less than adequate for all the tasks required of ROMPs.

Status and job satisfaction
The perceived high workload is also reflected in Table 5. Most respondents felt that the workload for medical physicists is too high. From the simple questions in the present survey, it is difficult to compare the results directly with 2008. However, it appears that workloads have increased while the professional recognition and remuneration has stayed more or less constant. In any case, it appears that the disparities between countries have not substantially reduced between 2008 and 2011.

Limitations of the survey
Any survey conducted with individuals representing whole countries and territories has limitations as many countries have complex healthcare systems with a large diversity of tasks and practices. A particular concern is the availability of public and private facilities in most countries that often serve different patient groups and may have considerably different equipment and work practices. The fact that only one person completed the survey in each country will introduce some bias to the results; however, the personal contact amongst the authors ensures that the response rate can be as high as it has been.
Another limitation is the fact that work practices of medical physicists in radiation oncology are different in different countries, as can be seen in Table 3. Therefore some tasks may actually be taken up by other professionals and possibly technicians. While this is not accounted for in the survey, it can be assumed that the physicists will also take on other responsibilities that are not part of their core duties. In assessing staff numbers per machine or population as in Table 2, it was assumed that there is a balance between delegated and newly acquired tasks.

CONCLUSION
As organisations such as the ILO start to recognise medical physics as a profession, it is evident that, despite some encouraging signs, there is still a lot of work required towards establishing an adequately trained and resourced medical physics workforce in the Asia Pacific region. The significant increase in the number of ROMPs in the region between 2008 and 2011 is matched by similar increases in radiation oncology equipment and complexity of treatment approaches. As further increases in the use of radiation for cancer treatment can be expected, it will be important to continue also the growth of the medical physics profession.